Understanding Your Fertility
Do I need to investigate my fertility? Understanding fertility and When to seek support
Written by Dr. Fiona Callender, ND
Infertility, broadly, is considered the inability to achieve a pregnancy after one year of trying. In Canada, the rate of infertility sits at about 1 in 6 couples. In people under 35, we usually start investigating after that year of trying, by running tests and asking more questions. In those older than 35, this evaluation starts a little earlier - after 6 months of trying. Your history here matters and other medical, sexual or reproductive history might also lead us to investigate or make referrals earlier. For instance, having irregular cycles or missed periods might be a prompt for an earlier investigation, as would known hormonal conditions such as PCOS and endometriosis.
What does it take to make a baby?
Fertility potential without intervention (in the wild!) requires a number of factors to align. We need a healthy oocyte (egg) and regular ovulation of that oocyte; functional sperm (requiring normal hormonal function and sperm producing activity); anatomical capacity for the sperm and egg to meet - meaning we have a functional cervix, uterus and fallopian tubes, as well as the epididymis and penis for the male party.
Once the oocyte and sperm have met, we also need to have capacity for implantation - meaning anatomically and hormonally appropriate uterine environment for the embryo to attach and thrive.
Although women often bear the weight of blame for infertility in a partnership, both male and female factors can play a role in our ability to achieve pregnancy. About 35% of couples will have both male and female factors involved and 10-20% may have male factor as the sole cause. This means about 50% may be attributed to male factors!
Age is our biggest adversary
Among all the pieces that have to fall in to place to make a baby, age remains the strongest predictor of success - whether that’s with or without the use of artificial technology. This is a factor that isn’t really able to be overcome with technology because we don’t yet have a way of assessing the “quality” of an egg. If someone has told you they can see you have low egg quality, you can ask them how they know that! With some testing, we can understand some factors involved in your fertility potential.
Understanding Ovarian Reserve
Ovarian reserve is typically understood in terms of both quantitative and qualitative aspects of ovarian aging. When we say qualitative, this is looking at genetic risk. This qualitative side of the ovarian pool is what is most closely tied to chronological age. The quantitative (number of oocytes) side of things can vary widely between women of the same age. Genetics is actually our strongest predictor of number of eggs we might have at a given age. Women are born with a finite number of oocytes, while men continue to produce new sperm. Though a man’s age does seem to have an impact - but that’s a conversation for another day! We now know that more than 50% of the age of menopause - the complete loss of functional oocytes - is heritable.
To measure our ovarian pool, we can look at your antral follicle count (AFC) and antimüllerian hormone (AMH) levels. These levels give us an idea of quantity, but not necessarily quality. AMH is a predictor of “functional ovarian reserve”, meaning the pool of growing follicles available in any given month. This is a good marker of quantity but doesn’t give us the full picture - it really needs to be interpreted in the context of the hormonal environment. Often patients really want to test AMH, but it can often lead to more stress - especially when it’s not necessarily a great predictor of pregnancy potential without intervention.
Factors that impact AMH
PCOS
Vitamin D status
Thyroid dysfunction
History of pelvic surgery
Chemotherapy
Obesity
Oral Contraceptive Use (though this returns to normal in the 3-6 months after stopping)
When we test AMH
AMH can be highly useful in predicting success in assisted reproductive technology cycles. It can help reproductive specialists determine what their strategy might be, how much stimulation may be needed, how many eggs might be retrieved etc. It’s not necessarily a bad test to run for fertility investigations in general, but it’s important to keep in mind that in couples attempting to conceive without intervention, low AMH versus high AMH doesn’t always make a huge amount of difference in terms of pregnancy rates. It’s something to consider and investigate or understand the reason, but it’s not on it’s own a valid predictor of success.
How I approach fertility in my office
This is a time in many people’s lives that is both exciting and emotional. Many have probably spent most of their adult life focusing on preventing pregnancy and this shift and challenge in trying to get pregnant can often come with stressors and emotions we weren’t expecting. My goal is always to support you with the information you need to be able to make the right choices for YOU. We spend the time to understand you as a person, your health history, family history, current symptoms or concerns, and usually run some blood work to investigate further. I often refer to therapy for additional support and, if needed, we get the ball rolling on a fertility clinic referral so it’s there if we need it. We can also discuss pelvic floor health and symptoms as part of an assessment if this makes sense for you. A lot of the work we do is to make you as healthy as possible, while addressing any underlying factors that might be getting in your way.
Curious about how naturopathic medicine can help support your fertility journey and family planning? Book a meet & greet appointment with Dr. Fiona to learn more about her approach!